Flexible Spending Account Forms

Flexible Spending Account (FSA) Change Form

Submit the Flexible Spending Account Change form to Benefits, Payroll and Retirement Operations to request changes to your flexible spending account within 30 days after a qualifying life event occurs. Benefits, Payroll and Retirement Operations will verify the changes and forward them to FBMC if they qualify.

FSA Reimbursement Claim Form

Submit the FSA Reimbursement Claim Form to FBMC as you incur eligible expenses during the calendar year. You may submit reimbursement forms until March 31 for previous year expenses.

Letter of Medical Need

Submit a Letter of Medical Need with your FSA Reimbursement Claim Form if the expense:

• can be provided for both a medical purpose and a cosmetic, personal, living and/or family purpose, and/or
• is a capital expenditure, which means the item you've purchased has a useful life extending beyond the end of the taxable year.

FSA Authorization for Automatic Reimbursement Deposits Form

Submit the Authorization for Automatic Reimbursement Deposits form to FBMC to have reimbursements deposited directly to your checking or savings account. You may set up direct deposit at any time.